Utilization Management Nurse I

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Requirements:

• Completion of an accredited nursing program or licensed practical nursing program.
• Active and unrestricted RN or LPN license in Iowa or South Dakota.
• 4+ years of diverse clinical experience that includes direct clinical care.
• Experience in a utilization management or health insurance setting is beneficial.
• Strong verbal and written communication skills.
• Commitment to service excellence and member advocacy.
• Ability to organize and manage multiple priorities.
• Strong technical skills, particularly with Microsoft Office and clinical documentation platforms.

Responsibilities:

• Provide members and health care providers with timely prior approval for services and procedures by obtaining necessary medical information.
• Assist in precertification and continued stay reviews for members in healthcare facilities.
• Collaborate with healthcare providers to ensure timely discharge planning.
• Process utilization management requests by interpreting medical policy and benefit information.
• Collaborate with interdisciplinary care teams to meet member needs.
• Document review processes and decisions accurately and timely.
• Comply with regulatory standards and internal guidelines.